Brief guide: Assessing mental health care in the emergency

department (ED)

Context

A significant proportion of attendees of all ages in the emergency department (ED) have a
significant mental health need, and many people attend ED directly because of mental
health needs. People with mental illness may attend the ED for a number of reasons,
including:

 seeking help where the mental illness is the primary issue – this can include drug and
alcohol issues

 self-harm requiring urgent medical treatment but with underlying serious mental illness
that requires evaluation

 mental illness incidental to a primary physical complaint (including those with learning
disability or autism)

 as a place of safety under section 136 of the Mental Health Act (MHA)

 for children and young people, mental health and risk issues occurring in a social care
context, including safeguarding.

Brief guides are a learning resource for CQC inspectors. They provide information, references, links to professional guidance, legal
requirements or recognised best practice guidance about particular topics in order to assist inspection teams. They do not provide
guidance to registered persons about complying with any of the regulations made pursuant to s 20 of the Health and Social Care Act
2008 nor are they further indicators of assessment pursuant to s 46 of the Health and Social Care Act 2008.

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Evidence required, key considerations under the inspection framework
and reporting

Safe

 ED staff who triage patients have received age appropriate mental health training and
use a tool to assess patients’ mental health to briefly gauge their risk of self-harm,
suicide and risk of leaving the department before assessment or treatment is
complete1,2.

 Liaison psychiatry team (these are adult focused) and ED team jointly devise risk
management plans for patients in the ED (parallel working)3.

 The ED should have clear plans in place for the mental health risk assessments for
children under 18. In some cases, assessments of children out of hours will be the
responsibility of the liaison psychiatry team, but there should be access at all times to a
CYP Psychiatrist. If liaison psychiatry are involved then there should be training in CYP.

 ED staff should be suitably trained in de-escalation and conflict resolution, and there
should be identified staff who have been suitably trained in restraint4,5. The Restraint

 Reduction Network Training Standards6 are not currently mandatory in acute services
but are considered best practice. Appropriately trained staff should be available for 1:1
observations for both adults and children.

 The ED follows guidance on manual restraint and rapid tranquilisation as set by The
National Institute for Health and Care Excellence (NICE)7.
1 Healthcare Safety Investigation Branch, Investigation into the provision of mental health care to patient presenting at
the Emergency Department (Nov 2018)
2 RCEM Mental Health Toolkit, (June 2021)
3 NHS England Achieving better access to 24/7 urgent and emergency mental health care
4 Brief guide for inspection teams: restraint (physical and mechanical)
5 RCEM National Survey on Security and Restraint in the ED. December 2020
6 The Restraint Reduction Network Training Standards (First Edition)
7 HYPERLINK "https://www.nice.org.uk/guidance/ng10/chapter/1-Recommendations" \l "managing-violence-
and-aggression-in-emergency-departments-2" NICE Guideline 10: Violence and aggression: short-term
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 Mental Health assessment rooms meet Psychiatric Liaison Accreditation Network
(PLAN) standards?8,9 Actions related to the National patient Safety Alert: Ligature and
ligature point risk assessment tools and policies have been completed10,11.

 There are policies and procedures for the management of patients at risk of self-harm
who are not being cared for in the MH assessment room. There should also be policies
and procedures for the management of self-harm in other non-clinical areas, such as
the toilets.

 There are policies and procedures for the observation of patients at high risk of harm to
themselves or others – for example patients that are highly distressed or confused.

 Staff understand rights under Mental Capacity Act (MCA) and MHA, and responsibilities
if at-risk patient attempts to leave ED. For children, they understand the Children’s Act
and Working together to safeguard children. Staff also understand the ‘Think Family’
approach and the assessment of risk to self and others and that details of any child that
is living with or has contact with will be recorded.

 All acute hospitals should have a lead pharmacist for prescribing related to mental
health and substance use disorders, who takes a lead in developing and auditing
policies regarding psychotropic prescribing. They should work closely with the liaison
psychiatry service and acute hospital ward pharmacists12,13.

 All patients who have harmed themselves are offered a psychosocial assessment
before being discharged from the ED1.

 Evidence of reasonable adjustments for people with a learning disability and autism in
ED.

Effective

management in mental health, health and community settings (2015) Section 1.5
8 Quality Standards for Liaison Psychiatry Services – Sixth Edition 2020
9 Brief Guide for inspection teams: Ligature points (in keeping with guidance around publishing information of this
nature, this brief guide is only available to CQC staff)
10 National Patient Safety Alert: Ligature and ligature point risk assessment tools and policies (March 2020) (in keeping
with guidance around publishing information of this nature, this brief guide is only available to CQC staff)
11 National Patient Safety Alerts (this is an intranet page only available to CQC staff)
12 RCP Liaison psychiatry for every acute hospital (2013)
13 Psychiatric Liaison Accreditation Network (PLAN): Type 2 Standard: All Liaison teams: 'The liaison team has access
to a specialised pharmacist and/or pharmacy technician to discuss medications.'
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 Good links with the liaison psychiatry team, or CYP equivalent. Consider skills and
leadership of liaison psychiatry team and evidence of joint working, location of liaison
psychiatry office14.

 Arrangements set up for a place of safety for children under 18. Arrangements for the
child to be transferred to a paediatric ward and onward.

 Clear Section 136 pathways – prompt access to Section 12 doctors and Approved
Mental Health Professional (AMHP).The police have a power, under section 136 of the
Mental Health Act, to remove from a public place any person an officer believes is
suffering from mental disorder and who may cause harm to themselves or another and
take them to a designated place of safety for assessment under the Act. The preferred
destination is usually a specific room or suite within a psychiatric unit for this purpose.
However, if the person requires medical treatment, e.g. following self-harm, they may be
brought to an emergency department15.

 Good links (for example joint polices and meetings, and supported training) with local
mental health trust for onward admission and / or follow-up of patients, and for mental
health advocacy.

 Arrangements in place for support and guidance in relation to the Mental Health Act.

 Access to Children and Young People’s Mental Health Services to include local
authority services, including advice (including out-of-hours).

 Access to learning disability services to meet people’s needs in a timely manner.

 Services understand that autistic people in ED may require reasonable adjustments to

optimise clinical contacts.

 Staff training in supporting people with mental health conditions (including those with a
CYP element), a learning disability and autistic people.

 Staff training in application of MCA and Children Act.

Responsive

 Consider response times (1 hour for urgent referrals)1 by adult liaison psychiatry teams.
Does the liaison psychiatry team undertake risk assessments or mental health

14 Note that the liaison psychiatry team may be employed directly by the acute trust, or may be provided by a third party
(most likely the local MH NHS Trust)
15 Mental Health Crisis Care Concordat - page 25
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 assessments of patients while patients are receiving care for their physical health
(parallel working)?

 Where possible, there are suitable waiting and treatment facilities for children and
young people who present with mental health needs16.

 Staff have had training and are aware of the needs of people with a learning disability or
autism and are able to make reasonable adaptations to waiting and treatment facilities.

 Carers and family members feel supported in ED.

 There is collaborative working with other providers to minimise waits for inpatient beds
in MH services, and long waits are escalated appropriately.

 Information for patients is available in a range of formats, including easy-read

information.

Well-led

 Evidence of joint strategic working between ED and liaison psychiatry service or the
CYP equivalent (policy review, environment and so on) and the local mental health
trust.

 Board level oversight and leadership of mental health issues in ED.

 Evidence that the provider’s governance framework ensures that MHA procedures are
followed and that hospital managers are fulfilling their duties and powers under the
MHA. As per the MHA Code of Practice 37.2 ‘In England, NHS hospitals are managed
by NHS trusts and NHS foundation trusts. For these hospitals (including acute/non-
mental health hospitals), the trusts themselves are defined as the ‘hospital managers’
for the purposes of the Act.

 Operational managers understand the position of ED in the Integrated Care System.

Link to regulations
16 RCPCH: Facing the future - standards for young people in emergency care settings
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Regulation 9, person centred care;

Regulation 10, dignity and respect;

Regulation 11, need for consent;

Regulation 12, safe care and treatment;

Regulation 13, safeguarding service users from abuse and improper treatment;

Regulation 14, meeting nutritional and hydration needs;

Regulation 15, premises and equipment;

Regulation 17, good governance and;

Regulation 18, staffing.

Further support

For CQC staff only, further training for the Assessment of Mental Health Services in
Acute Trusts is available on ED – see AMSAT: Assessing Mental Health in Acute Trusts.
For specific MHA related queries please contact MHPolicy@cqc.org.uk or MHA
reviewers17.

17 Assessment by inspectors of how a provider applies the MHA.

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